Repeal Obamacare, go back to HSAs. Nobody should be taxed on health expenses, which was the whole point of HSAs in the first place. We literally had a budding system that was working and affordable, and it was "fixed".
Define "budding system that was working". Before the ACA, the number of uninsured Americans was around 50 million and insurance companies routinely denied coverage or charge higher premiums based on pre-existing health conditions. ACA is not perfect (due in no small part to the concessions that had to be made in congress to get enough votes) but i'd say it's been a net win.
Going back to a pre-ACA system won't lower premiums that much. Medical costs have risen in the last decade, same as any other goods or services, and the way US healthcare is structured, with hospital and doctors negotiating with a profit driven middleman (insurance companies) makes it almost impossible to change the rising premiums.
US healthcare will continue to be a mess until there's a universal healthcare system or single payer system similar to any other developed country on earth.
I have been struggling to find the breakeven point for me and my family. On one side, it keeps getting more and more expensive even though we are young and healthy. On the other, if one of us needs an expensive operation or months of treatment, no amount of HSA savings will be enough. I don't know if there is a 3rd option that would be more reasonable.
The third option that becomes more tantalizing every year in the US is to not have insurance, pay OOP for routine matters, and when something catastrophic happens let the medical debt go to collections and settle for pennies on the dollar. It doesn't feel right, but it's the direction the medical-pharmaceutical-insurance cartel is pushing us.
Reading the comments is hilarious. That "healthy 34 year-old male with minor sports injuries" was exactly me when I was 34. Then I hit my out-of-pocket max 7 out of the next 10 years and exceeded a million in insurance spend twice due to a whole lot of major surgeries. It also feels male-centric. Surely pregnancy and childbirth are all but guaranteed to put you over an out-of-pocket max, especially with how common c-sections are these days.
And then you have to wonder how many operations are done just to bill insurance companies money. I have injured my shoulder(here in the UK) and I saw a specialist shoulder surgeon who basically said that the state of the art research into these kinds of injuries is to just leave them alone and let them heal - but if you were in the US you would have had two operations on it already because they just love operating on things that don't need operating on for dubious medical benefit because they would charge 100k for each operation, easy.
OP is a privileged take, yes. If you touch grass in poverty spaces, disability spaces, etc., there are a lot of preventable things that could be done or mitigations that could be made that would reduce future costs to society and individuals in incredible ways but are not done because people lack the resources to pursue them. The insurance model is flawed in practice for young, healthy, male IT workers yes, but that's just a testament to how broadly flawed it is that even those positions of privilege are being failed by it.
Big picture: As a society we are failing to make investments in population health that would pay off and an industry exists in a position that it is directly antagonistic to social good. Medical bankruptcies when an under-insured person has a catastrophe is a failure. A person avoiding preventative or corrective care that will improve their future because in the present they need to pay rent instead is a failure. The market dynamic on private insurance creates pressures that produce these failures as a matter of course. Maybe single-state-payer isn't a perfect way to do this (I am pro-social but also a minarchist), but the private insurance model is obviously worse, and there's probably some solution to the holistic problem but we're incredibly bad at whole-system and whole-population thinking, accounting for "undesirables", and probability around unlikely catastrophe, (and propagandized into being even worse at these things than human psychology alone would allow) so any solution which is optimal is likely to be incredibly unpopular because at the individual optimistic case level it'll feel like it's "infantilizing" people or creating individual disincentives for "repsonsibility" or whatever, and that's before we get to the part where we have large populations of people who are so comfortable with hierarchical systems of exploitation that they are afraid improving things substantially means their currently-comfortable above-water status in the pile of drowning rats might be threatened.
Indeed, healthy or not, once you hit 40s .. the number of friends/family/self dealing with accidents/injuries/serious illness/death grows exponentially.
The article mentions early a "cancer diagnosis" but puts that aside and moves on, when this is pretty much the crux of the issue. Prostate and Breast cancers are a 1 in 8 chance. The risk of no insurance at 25 is very different than 50, and than 75. And everyone at all ages is paying for those expensive treatments.
The system is broken, but going without insurance is you basically toying with the odds of life.
In a perfect world, a healthcare plan should pay for cancer treatments or crucial medical procedures. In the United States, I'm not sure this is a guarantee[0][1]. Going without healthcare seems to be the riskier gamble, but it's a gamble either way.
Pre-ACA my mother got cancer in a short window where the University my Dad was president of got wound down for financial reasons.
Destroyed my entire trajectory in life.
The prior system was mega fucked, our current system is still fucked.
If you had a congenital condition prior to the ACA you were a wage slave once you hit 18, no private insurance and couldn't get public. Literally founded a successful startup the minute I got ACA.
Over 40+ years I've seen nearly every profession go through a bubble and lean years, lawyers, mechanics, academics.
But never doctors, in retrospect I should have joined that protectionist racket, but my family couldn't afford to let me at the time.
If you get a very serious and expensive problem, insurance may not help nearly as much as you'd think. My mother had great insurance, but when she got cancer, the insurance didn't stop her from getting absolutely destroyed by the medical bills (not to mention having to constantly fight with the insurance company while being extremely ill).
It drove her to bankruptcy anyway. In hindsight, she commented that had she known that the insurance wouldn't be all that helpful, she would have just saved up all the money she poured into premiums over the decades.
Author here. I'm definitely not advocating going without health insurance. Just running simple numbers to get some perspective.
I'd like to see health insurance act like insurance again though. Right now it covers absolutely everything, meaning it's more like pre-payment for routine care + insurance.
Insurance isn't for routine, predictable, or low-cost expenses. But we've mandated that our health insurance cover all of those things.
The comparison to car insurance is overused, but it's a good one. Catastrophic coverage + dedicated savings with lower premiums looks more attractive to a lot more people.
Direct primary care was a completely game-changing improvement in healthcare for me.
$95/mo to basically subscribe to a local doctor. Covers most things other than tests or surgery or limb setting. But tests are often very discounted relative to what insurance charges for them (with my previous dpc provider an entire battery of tests cost less through them than just the copay for two of them added up to).
It’s remarkable how different it is when the healthcare provider is focused on you and your health rather than on gaming the metrics by which insurance companies judge them.
Make other plans for catastrophic things (ie, a high deductible insurance plan).
I do this too and I love it, and it highlights what to me is the healthcare's system biggest constraint. It is amazing how little healthcare can cost when you do not need to staff seven paper pushers for every doctor.
My big question about DPC is: what about people who just don't think about primary care until they have something wrong? How long is the wait list at that point? Or can they go see a doctor for $X as a one-off, without a subscription?
It's a good option for primary care. It's also a form of insurance, since the reason why it's low is that enough people will subscribe but not use it, just like the gym :)
The issue is that primary care is not generally expensive, and also not generally needed if you're healthy. I've gone to a PCP less than half-dozen times in my 56 years. So the $100/mo is a waste in my case -- I save much more by just paying out of pocket if every I need to go.
But medical expenses for unexpected conditions -- surgeries, specialized tests, visits with specialized doctors, non-routine medications -- those are all what cost a lot. And that's not covered by $100/month.
So DPC is a nice idea, but it doesn't really replace health insurance -- I look at it more as an "extra" for regular health monitoring and preventative care, which is important in itself (and in most cases worth the $100/month).
The truth is that Us health insurance industry has proven it is not about providing healthcare but instead capital extraction. The whole thing is seen as rotten by every participant.
What has happened is that it’s now more affordable to get healthcare in foreign countries as an American. I can vacation and get whatever care I need by doctors in countries with healthcare systems. Doctors that are incentivized to provide healthcare. In economies where people are proud to have a job.
There are some good doctors in the Usa but they are incentivized to charge as much as possible and put patients into studies or experimental drugs to get kickbacks. It costs me $50 to get my results from my doctor. They refuse to send an email and a phone call means it’s a “telehealth” appointment. Which is not a medical or technical health term but the name of the product category.
Usa does __not__ have a healthcare system but instead a capital extraction health-insurance system that rarely helps with your health costs.
I wish this topic was better understood and was in the spotlight during Biden’s term as Potus. But we made extra sure to snub Bernie when Biden ran the first time. No surprise for me if nothing changes. Seems to only be a major topic during the years when affordability is an issue. So when affordability isn’t an issue we’re just A-Ok as Americans with the grifting health-insurance industry.
As a transplant to the states its absolutely astonishing to me how quickly doctors have pushed friends and family down the path of crazy expensive boutique treatments for issues that could simply resolved with more care and attention from clinicians.
I'm not saying some these drugs don't work astonishingly well and for some people they are a miracle/lifesaving treatment but still. Drugs that are in excess of a thousand dollars a pill out of pocket blows my mind.
Health insurance companies are a not the problem, their stocks are trash because their business sucks for profitability. They're not the rich misers swimming in gold piles that they are made out to be. People just get that feeling because the insurers are the proxy for medical costs, but you don't have to dig deep to see that they are getting bent too.
It is worth it imo but it could be better. This is my back of napkin mental model but I have convinced myself that most of our troubles are because health insurance morphed from truly emergencies to every day care. Routine care (both primary and specialist) have to hire deep staff to handle insurance claims with the different payers. It’s a constant game.
For myself I always pick the high deductible plan. It’s the next best thing to an emergency only plan in my opinion. I am also lucky that I have an employer that picks this kind of plan as an option. Everyone should be on this type of plan imo. I think have a direct primary care (directs don’t take any insurance) for the family that costs $200 a month for 3 of us. The insurance cost is $100 with a max out of pocket I think around $8000. Now we are lucky in that these dollar figures don’t bother us, not true for everyone but I do think most of us would be better off if we have better forms of true emergency insurance. I want to pool the risk of a catastrophic illness or accident, not my doctors visit for a cough.
I pay my dpc directly for all testing and it’s cheap. A lot cheaper than if it was billed via insurance.
Study after study finds that a health care model where you can visit a doctor frequently leads to much better overall heath for people.
The system we have here forces people to wait until minor issues turn into life or death situations that require much more intensive and expensive care.
I think what this misses is that insurers handle the hassle of dealing with negotiated rates.
As an example, if you go to the ER and get a strep test, you might be billed $500, and insurance will pay $7 (as ridiculous as this sounds). If you go at this on your own, they'll probably bill you $100 and tell you they are giving you an 80% discount. With lots of phone calls, you can maybe get them down to $50.
This is all obviously crazy. But it makes it such that you really do want insurance if you can afford it. More so, even if you are a billionaire and can afford to self insure, it still makes sense to have health insurance (whereas property or life insurance probably don't make sense for you).
Also, don't forget that insurance premiums are often tax deductible for wealthy people, so the actual amount paid is less.
Dental insurance is even worse. My dental insurance has ridiculously low limits, but it gets you access to the "real" negotiated rates rather than whatever silliness "retail price" is.
I tried going without when I switched jobs to an employer that doesn't offer it, but one cleaning as a "cash payer" cost more than the annual premiums to buy insurance privately.
Executive order 14221 (passed in 2021, [0]) was supposed to provide transparency about what the actual negotiated rates were. The idea was that it would be a lot harder for hospitals to engage in price discrimination when they had to publish what everyone was paying.
The actual effect has been... mixed. IIUC, the hospitals mostly haven't complied with the order, or they're maliciously complying while trying to keep their real rates secret.
I just looked at the local marketplace plans. The absolute dirt-cheapest I could do for my family is ~$1,225/month premium with a deductible of $13,400 and out-of-pocket max of $21,200. Most of the structure is some form of "zero help until the deductible, then I pay 20%-40% of everything up until the OOP max".
In other words, I'm being asked to buy a product, and the cheapest form of it is to basically pay almost $15k in a year to hedge against someone getting cancer or whatever, and actively incentivizes me to not use it[0].
There is no meaningful shopping around, there is no incentive for me to do anything other than continue not smoking, there's no accounting for where I live or my health.
I dunno what the solution is. I'm just glad that the ACA included health sharing co-ops as an exception. Been doing that for awhile now and have saved a lot of money. (And they'll give me a discount if I get my weight down a little more!)
[0]: Because even if you get a free wellness visit or whatever, it's really easy for them to drop in some random test that ends up getting billed. Had this happen with my kids a few times if memory serves.
It was never sustainable. Because the model relied on healthy people subsidizing the people who make extremely poor choices (obesity, smoking, drugs or a combination of that). Obamacare's modeling predicted that significantly more healthy people would sign up, driving costs down. It didn't happen.
Now it is a system that ONLY the unhealthy benefit from. Everyone else pays for extremely bad choices.
So you have to pay like $30k out of pocket in a year before the insurance chips in a single dollar? And if you ever ask for a dollar, I can also reject your coverage.
That seems... fine? That's $14,000 annually. For an income in the $75k-$100k range, Maryland health connection shows me a premium of $700/month for two parents/two kids. Judging by your premium and assuming 2 adults/2 kids, your income is probably over $200k. With that income in Canada, you'd be paying over $20,000 in taxes attributable to healthcare: https://www.fraserinstitute.org/sites/default/files/price-of....
Now you have to account for taxes you pay in the U.S. for medicare, and a risk-adjusted share of the deductible payments, but overall it doesn't seem that crazy.
> In other words, I'm being asked to buy a product, and the cheapest form of it is to basically pay almost $15k in a year to hedge against someone getting cancer or whatever, and actively incentivizes me to not use it[0]
You are not paying $15k to hedge against someone in your family getting cancer in a calendar year.
You are paying $15k to pay for old and sick people’s routine healthcare, due to the ACA’s requirement that the highest premium to be at most 3x the lowest premium, and the requirement that premiums be only a function of age and tobacco use (i.e. no underwriting for health risks by factoring in pre existing conditions).
So an ACA compliant health plan’s premiums are far more comparable to a tax than an insurance premium since they are explicitly a wealth transfer mechanism from young and healthy to old and sick.
New York state takes this wealth transfer even further and mandates that age not be used at all to price premiums. I think Massachusetts only allows an age rating factor of 2.
The actual cost to treat "cancer or whatever" is extremely high in many cases. 15k a year to know you have that covered for a family isn't so bad given the true underlying cost.
A family member has a rare disease and I've gone through the details of the various treatments, how many people are involved in ongoing care and treatment etc. It's a lot of very well trained people spending a lot of time. A concrete treatment example - the process to create some blood plasma treatments is very complex, expensive etc. In the end, it will be millions of dollars of real underlying costs.
There is probably no cheap solution. Maybe GLP-1 type magic can put a real dent in the overall cost, but there will always be a desire to save people's lives even if the cost is very high.
All I want is health insurance with low premiums, freedom to choose my providers, and a $50k deductible. Like, actual insurance for catastrophic risks. What we have now should not properly be called insurance. It's more like a mandatory membership in an extremely expensive and dysfunctional club.
My parents use a shocking amount of healthcare services, considering that they are pretty normal 70-somethings. My dad has well managed diabetes and blood pressure, and my mom is pre-diabetic and has a bad knee, but that's about it. Their parents all made it to their 80s without modern medical care in Bangladesh. My kids don't use any healthcare services, but we're always been offered services. My younger one has low muscle tone, and we could get physical therapy for that. We had a (free) county evaluation for his speech delay. The evaluator said something along the lines of "we could give him a diagnosis so he could get services in public school, but since you send him to private school it's not worth it."
I'm not saying this is unnecessary, nor am I qualified to do so. My point is that we seem to be getting a lot more healthcare than was typical when I was a kid. So it's unsurprising premiums have skyrocketed.
You can always make the argument that insurance, no matter what it covers, isn't worth it. You're paying for coverage in the case something goes wrong. If it doesn't go wrong, you don't get your money back. The one exception to this is Old-Age, Survivors, and Disability Insurance, better known as Social Security. For some reason, we feel the need to mail checks to, statistically speaking, the wealthiest age demographic in the country whether they need it or not.
But is health insurance worth it?
If you're a very lucky and healthy 25-year-old with no dependents and six figures in the bank, maybe not.
Everyone else? I don't know. That would depend on things like your state's bankruptcy laws. What's not to love about the bankruptcy process?
The major problems with health insurance in the US are that 1) there is no basic public option that everyone could use if they absolutely had to, and 2) the largest providers are for-profit, meaning that they have to satisfy the free riders known as shareholders.
Is medical tourism a potential option for uninsured people to decrease costs in the event of major illness like cancer? How about for a chronic condition?
I'm not (yet) willing to do this for general health insurance, but I made this decision for dental, a couple of years ago. It has not been an issue. I've had a couple of crowns, and paid a fraction of what insurance would have covered, minus the ridiculously high deductible, and the monthly premiums.
Of course, now it's time to re-up for next year, and the message seems to be "Squeal, boy!".
I think this is worth considering for younger folks, but I wanna point out how low the numbers in the "medical expense" column are. They're similar (if low) for routine care but if you have an actual emergency you'd have much higher bills. IIRC when my mom had breast cancer she was getting a weekly shot to inhibit the HER2/neu mechanism of her cancer that had a list of $10,000 a shot. As an uninsured person you won't pay list but you are rolling the dice pretty hard. Insurance costs are highway robbery - and also the part of their prices that aren't driven by greed are driven by absurd underlying costs.
> 1. What would happen if instead of buying health insurance, you set aside annual premiums plus your deductible every year and paid out of pocket?
What would happen if healthcare was a shared pool for the often-unpredictable risk for everyone, so that everyone was taken care of?
This is obviously a government function in the interests of everyone, so there's no need for profit-taking insurance companies with perverse incentives.
Any good explanations as to why insurance companies haven't merged? Each provide roughly the same service. Instead of one staff (and one highly paid exec team and management hierarchy), our healthcare spending has to support a dozen or so, and for what gain to the consumer?
I think to address the problem we should first address the language.
It is not largely health insurance, it is medical treatment payment insurance, so I usually just call it medical insurance.
We are not paying so much money for promotion of or preservation of health, or even early detection of disease. We are paying so much for late medical treatment of disease
When I was child, our dog got hit by a car. The dog had two broken legs and was bleeding from the nose. My dad said, "Come with me son, I will show you what to do." So we went into the woods behind the house and dug a hole. I put the dog in the hole and my dad shot the dog in the head. After we filled in the hole my dad said. "Now you know what to do with me when I get old."
So my health insurance is healthy living, CrossFit, rapamycin etc. When that fails, I have a 9mm pistol I keep in the safe. I do worry about if I am somehow too incapacitated to use the pistol but not enough to die naturally. Infirmity scares me a lot more then death does.
The only reason we have this broken system in the US is because of "lobbying" in an environment where unlimited money is "free speech". As long as these "insurance" companies continue to own the politicians, there will never be any meaningful progress. A 6% tax hike each year would induce riots in the streets, but somehow this same scenario in premiums is accepted by the population with anger and a shrug.
In the last two years, my mother had a tumour (successfully) removed from her brain and my sister had day-long heart surgery. Two extensive processes with lots of consults before and after, both requiring significant hospital stays. At the time I was a bit grumpy that I had to pay $15 a day for parking at the hospital, which was really the only out of pocket cost to the family here in Canada.
We do have a major shortage of GPs and wait times can be longer than you want, so I would not say that we necessarily have the best health care system in the world. But you really need to go to the cafeteria in a hospital to find cash registers. And when I picked up my mother from the hospital, we said goodbye to the nurses and just walked right out.
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[ 3.4 ms ] story [ 69.6 ms ] thread[0]: https://www.commonwealthfund.org/publications/issue-briefs/2...
Going back to a pre-ACA system won't lower premiums that much. Medical costs have risen in the last decade, same as any other goods or services, and the way US healthcare is structured, with hospital and doctors negotiating with a profit driven middleman (insurance companies) makes it almost impossible to change the rising premiums.
US healthcare will continue to be a mess until there's a universal healthcare system or single payer system similar to any other developed country on earth.
There may be something less extreme, but leaving the US is one way out of that mess.
Big picture: As a society we are failing to make investments in population health that would pay off and an industry exists in a position that it is directly antagonistic to social good. Medical bankruptcies when an under-insured person has a catastrophe is a failure. A person avoiding preventative or corrective care that will improve their future because in the present they need to pay rent instead is a failure. The market dynamic on private insurance creates pressures that produce these failures as a matter of course. Maybe single-state-payer isn't a perfect way to do this (I am pro-social but also a minarchist), but the private insurance model is obviously worse, and there's probably some solution to the holistic problem but we're incredibly bad at whole-system and whole-population thinking, accounting for "undesirables", and probability around unlikely catastrophe, (and propagandized into being even worse at these things than human psychology alone would allow) so any solution which is optimal is likely to be incredibly unpopular because at the individual optimistic case level it'll feel like it's "infantilizing" people or creating individual disincentives for "repsonsibility" or whatever, and that's before we get to the part where we have large populations of people who are so comfortable with hierarchical systems of exploitation that they are afraid improving things substantially means their currently-comfortable above-water status in the pile of drowning rats might be threatened.
The system is broken, but going without insurance is you basically toying with the odds of life.
[0]: https://www.startribune.com/unitedhealthcare-part-of-95m-set...
[1]: https://www.propublica.org/article/unitedhealth-healthcare-i...
Destroyed my entire trajectory in life.
The prior system was mega fucked, our current system is still fucked.
If you had a congenital condition prior to the ACA you were a wage slave once you hit 18, no private insurance and couldn't get public. Literally founded a successful startup the minute I got ACA.
Over 40+ years I've seen nearly every profession go through a bubble and lean years, lawyers, mechanics, academics.
But never doctors, in retrospect I should have joined that protectionist racket, but my family couldn't afford to let me at the time.
It drove her to bankruptcy anyway. In hindsight, she commented that had she known that the insurance wouldn't be all that helpful, she would have just saved up all the money she poured into premiums over the decades.
I'd like to see health insurance act like insurance again though. Right now it covers absolutely everything, meaning it's more like pre-payment for routine care + insurance.
Insurance isn't for routine, predictable, or low-cost expenses. But we've mandated that our health insurance cover all of those things.
The comparison to car insurance is overused, but it's a good one. Catastrophic coverage + dedicated savings with lower premiums looks more attractive to a lot more people.
$95/mo to basically subscribe to a local doctor. Covers most things other than tests or surgery or limb setting. But tests are often very discounted relative to what insurance charges for them (with my previous dpc provider an entire battery of tests cost less through them than just the copay for two of them added up to).
It’s remarkable how different it is when the healthcare provider is focused on you and your health rather than on gaming the metrics by which insurance companies judge them.
Make other plans for catastrophic things (ie, a high deductible insurance plan).
https://www.dpcfrontier.com/
The issue is that primary care is not generally expensive, and also not generally needed if you're healthy. I've gone to a PCP less than half-dozen times in my 56 years. So the $100/mo is a waste in my case -- I save much more by just paying out of pocket if every I need to go.
But medical expenses for unexpected conditions -- surgeries, specialized tests, visits with specialized doctors, non-routine medications -- those are all what cost a lot. And that's not covered by $100/month.
So DPC is a nice idea, but it doesn't really replace health insurance -- I look at it more as an "extra" for regular health monitoring and preventative care, which is important in itself (and in most cases worth the $100/month).
What has happened is that it’s now more affordable to get healthcare in foreign countries as an American. I can vacation and get whatever care I need by doctors in countries with healthcare systems. Doctors that are incentivized to provide healthcare. In economies where people are proud to have a job.
There are some good doctors in the Usa but they are incentivized to charge as much as possible and put patients into studies or experimental drugs to get kickbacks. It costs me $50 to get my results from my doctor. They refuse to send an email and a phone call means it’s a “telehealth” appointment. Which is not a medical or technical health term but the name of the product category.
Usa does __not__ have a healthcare system but instead a capital extraction health-insurance system that rarely helps with your health costs.
I wish this topic was better understood and was in the spotlight during Biden’s term as Potus. But we made extra sure to snub Bernie when Biden ran the first time. No surprise for me if nothing changes. Seems to only be a major topic during the years when affordability is an issue. So when affordability isn’t an issue we’re just A-Ok as Americans with the grifting health-insurance industry.
I'm not saying some these drugs don't work astonishingly well and for some people they are a miracle/lifesaving treatment but still. Drugs that are in excess of a thousand dollars a pill out of pocket blows my mind.
For myself I always pick the high deductible plan. It’s the next best thing to an emergency only plan in my opinion. I am also lucky that I have an employer that picks this kind of plan as an option. Everyone should be on this type of plan imo. I think have a direct primary care (directs don’t take any insurance) for the family that costs $200 a month for 3 of us. The insurance cost is $100 with a max out of pocket I think around $8000. Now we are lucky in that these dollar figures don’t bother us, not true for everyone but I do think most of us would be better off if we have better forms of true emergency insurance. I want to pool the risk of a catastrophic illness or accident, not my doctors visit for a cough.
I pay my dpc directly for all testing and it’s cheap. A lot cheaper than if it was billed via insurance.
The system we have here forces people to wait until minor issues turn into life or death situations that require much more intensive and expensive care.
DPC is terrific if you have an option near you! Paired with catastrophic insurance, it's a great bet for relatively healthy people.
The DPC Alliance map is well worth a visit: https://mapper.dpcfrontier.com/
And I wrote about DPC a while back: https://church.substack.com/p/direct-primary-care
As an example, if you go to the ER and get a strep test, you might be billed $500, and insurance will pay $7 (as ridiculous as this sounds). If you go at this on your own, they'll probably bill you $100 and tell you they are giving you an 80% discount. With lots of phone calls, you can maybe get them down to $50.
This is all obviously crazy. But it makes it such that you really do want insurance if you can afford it. More so, even if you are a billionaire and can afford to self insure, it still makes sense to have health insurance (whereas property or life insurance probably don't make sense for you).
Also, don't forget that insurance premiums are often tax deductible for wealthy people, so the actual amount paid is less.
I tried going without when I switched jobs to an employer that doesn't offer it, but one cleaning as a "cash payer" cost more than the annual premiums to buy insurance privately.
The actual effect has been... mixed. IIUC, the hospitals mostly haven't complied with the order, or they're maliciously complying while trying to keep their real rates secret.
[0]: https://www.cms.gov/priorities/key-initiatives/hospital-pric...
In other words, I'm being asked to buy a product, and the cheapest form of it is to basically pay almost $15k in a year to hedge against someone getting cancer or whatever, and actively incentivizes me to not use it[0].
There is no meaningful shopping around, there is no incentive for me to do anything other than continue not smoking, there's no accounting for where I live or my health.
I dunno what the solution is. I'm just glad that the ACA included health sharing co-ops as an exception. Been doing that for awhile now and have saved a lot of money. (And they'll give me a discount if I get my weight down a little more!)
[0]: Because even if you get a free wellness visit or whatever, it's really easy for them to drop in some random test that ends up getting billed. Had this happen with my kids a few times if memory serves.
Now it is a system that ONLY the unhealthy benefit from. Everyone else pays for extremely bad choices.
How can I start an insurance company?
Now you have to account for taxes you pay in the U.S. for medicare, and a risk-adjusted share of the deductible payments, but overall it doesn't seem that crazy.
You are not paying $15k to hedge against someone in your family getting cancer in a calendar year.
You are paying $15k to pay for old and sick people’s routine healthcare, due to the ACA’s requirement that the highest premium to be at most 3x the lowest premium, and the requirement that premiums be only a function of age and tobacco use (i.e. no underwriting for health risks by factoring in pre existing conditions).
So an ACA compliant health plan’s premiums are far more comparable to a tax than an insurance premium since they are explicitly a wealth transfer mechanism from young and healthy to old and sick.
New York state takes this wealth transfer even further and mandates that age not be used at all to price premiums. I think Massachusetts only allows an age rating factor of 2.
A family member has a rare disease and I've gone through the details of the various treatments, how many people are involved in ongoing care and treatment etc. It's a lot of very well trained people spending a lot of time. A concrete treatment example - the process to create some blood plasma treatments is very complex, expensive etc. In the end, it will be millions of dollars of real underlying costs.
There is probably no cheap solution. Maybe GLP-1 type magic can put a real dent in the overall cost, but there will always be a desire to save people's lives even if the cost is very high.
I'm not saying this is unnecessary, nor am I qualified to do so. My point is that we seem to be getting a lot more healthcare than was typical when I was a kid. So it's unsurprising premiums have skyrocketed.
But is health insurance worth it?
If you're a very lucky and healthy 25-year-old with no dependents and six figures in the bank, maybe not.
Everyone else? I don't know. That would depend on things like your state's bankruptcy laws. What's not to love about the bankruptcy process?
The major problems with health insurance in the US are that 1) there is no basic public option that everyone could use if they absolutely had to, and 2) the largest providers are for-profit, meaning that they have to satisfy the free riders known as shareholders.
Of course, now it's time to re-up for next year, and the message seems to be "Squeal, boy!".
What would happen if healthcare was a shared pool for the often-unpredictable risk for everyone, so that everyone was taken care of?
This is obviously a government function in the interests of everyone, so there's no need for profit-taking insurance companies with perverse incentives.
It is not largely health insurance, it is medical treatment payment insurance, so I usually just call it medical insurance.
We are not paying so much money for promotion of or preservation of health, or even early detection of disease. We are paying so much for late medical treatment of disease
So my health insurance is healthy living, CrossFit, rapamycin etc. When that fails, I have a 9mm pistol I keep in the safe. I do worry about if I am somehow too incapacitated to use the pistol but not enough to die naturally. Infirmity scares me a lot more then death does.
We do have a major shortage of GPs and wait times can be longer than you want, so I would not say that we necessarily have the best health care system in the world. But you really need to go to the cafeteria in a hospital to find cash registers. And when I picked up my mother from the hospital, we said goodbye to the nurses and just walked right out.